Welcome to my practice. Since it is important that you know how we will work together, this document answers important questions client’s often ask and provides information that I believe is important for you to understand. After you read this document and believe you understand what it means, you will be asked to sign it indicating you have read it and agree to its conditions. You will then be given a copy for your own files.

CONFIDENTIALITY

All information disclosed at sessions and written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.

When Disclosure is Required by Law: When there is a reasonable suspicion of child, gravely disabled person, animal, or elder abuse or neglect; when a client presents a danger to themselves, i.e., suicidal; or a danger to others, prenatal exposure to controlled substances, I’m professionally required to notify legal authorities and make reasonable attempts to notify the family of the client. Also when there is the contemplation and possible future commission of a crime or harmful act.

When Disclosure May be Required: Pursuant to a legal proceeding when you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain psychotherapy records and/or testimony from Ms. Lawless. In addition if you lodge a complaint with a consumer licensing board your records may be required to validate your complaint.

Emergencies: If there is an emergency during our work together, or in the future after termination where Ms. Lawless becomes concerned about your safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive proper medical care. For this purpose, she may also contact the person whose name you have provided to contact in an emergency and/or your immediate family.

Health Insurance: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process claims and authorize treatment. Only the minimum necessary information will be communicated to the carrier. Ms. Lawless has no control or knowledge over what insurance companies do with the information she submits to them as required, or who has access to this information.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you or your attorney’s, nor anyone else acting on your behalf will call on L. Lawless, unless absolutely necessary, to testify in court or at any proceeding, nor will a disclosure of the psychotherapy records be requested for these purposes.

Consultation: L. Lawless consults regularly with other professionals regarding her clients to optimize treatment; however, client’s names or other identifying information are never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.

Considering all of the above exclusions, if it is still appropriate, upon your request, L. Lawless will release information to any agency/person you specify unless L. Lawless assesses that releasing such information might be harmful to you in any way.

YOUR RECORDS

I keep and maintain records of our sessions together and maintain in your records any communication between sessions, and information provided to me by other professionals. In the case I am away for an extended amount of time or on vacation the professional covering my practice, and my Custodian of Records, will have access to your records should an emergency require it. These records are kept under two (2) locks and are only available to others with your release or under the conditions noted above. I will maintain these records for 10 years or more (or 10 years after your age of majority) and attempt to notify you when they are to be destroyed). You have the right to review or receive a summary of your records at any tine, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice.

TELEPHONE & EMERGENCY PROCEDURES

If you need to contact L. Lawless between sessions, please leave a message on the answering service 415.356.9809. Your call will be returned as soon as possible. Please call between 9 A.M. and 6 P.M. for non-emergency calls. Call between 6 P.M. and 9 A.M. only if it is urgent. L. Lawless picks up her messages several times a day. If an emergency situation arises, please indicate it clearly in your message. Ms. Lawless’s Cellular Telephone number is 707.333.3454. If you are experiencing a crisis and are unable to reach me, immediately call 911 and tell the dispatcher the nature of the emergency and your location.

E.MAIL & TEXT MESSAGES

I cannot guarantee the confidentiality of electronic communications, so unless agreed to otherwise, I will not respond to electronic queries.

FEES & PAYMENTS

Clients are expected to pay the standard fee of $175 per 50-minute session at the end of each session or at the end of the month unless other arrangements have been made, e.g., Managed Care Organization contractual payment. Payments can be in the form of cash, checks or credit card. Telephone conversations, site visits, report writing and reading, consultation with other professionals, longer sessions, E.Mail responses, and travel time will be charged at the same rate, unless agreed to otherwise. Please notify L. Lawless if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance company, making you ultimately responsible for all balances due. Unless agreed upon differently, L. Lawless will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. Insurance companies reimburse not all issues/conditions/problems, which are the focus of psychotherapy. It is your responsibility to verify the specifics of your coverage. If, for any reason, a balance due is not paid at the end of the month we will discuss a payment plan, or look at other options for treatment in other settings that are more affordable.

Missed Appointments: Since scheduling an appointment involves the reservation of a time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, if you miss a prearranged session you will be billed full fee for that time. Client vacations that fall on regularly scheduled session times are not billed when I have been notified ahead of time as indicated above. You will be notified of my non-emergency absences and vacations at least two (2) weeks ahead of time.

Emergencies

Sometimes I am called out of the office for client emergencies or have family emergencies of my own. I will do my best to contact you and make arrangements for a meeting that is interfered with due to any emergency that arises, and assume you will do the same. Each “emergency” absence will be individually discussed.

If I experience a personal emergency and am not able to provide services, am on vacation or unable to get to my office for a regularly scheduled appointment, I have appointed a colleague, Debby Bergstrom, to be my Custodian of Records. Upon receiving a call from myself or a designee, she will notify my clients of the emergency event. She will have access to your records as appropriate to your needs. All information will be transferred in

HIPAA compliant standards.

DUAL RELATIONSHIPS

Therapy never involves business, friendship or sexual relationships or any other relationship that impairs L. Lawless’s objectivity, clinical judgment, and therapeutic effectiveness or can be considered exploitative in nature.

THE PROCESS OF THERAPY

Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships and the specific concerns that led you to seek therapy. Working toward these benefits; however, requires effort on your part. Psychotherapy requires your active involvement in the process, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, or experiencing anxiety, depression, or insomnia, for example. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite differently by another family member. Change will sometimes be easy and swift, but can also be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I will draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches can include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental, body-mind, wholistic, or psychoeducational interventions.

Treatment Planning

Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, or about the treatment plan, please ask. You also have the right to ask about other treatments for your condition and issues, and their risks and benefits. If you might benefit from any treatment I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

SOCIAL MEDIA POLICIES

Friending

I do not accept friend requests from current or former clients. This holds true on Facebook and LinkedIn and all other social networking sites. My reasons for this stance are that I believe that adding clients as friends can compromise confidentiality and blur the boundaries of our therapeutic relationship. If you have questions about this, please feel free to bring it up in-session and I’m happy to talk more about it.

Fanning

I maintain a Facebook page for my professional practice. I do not allow clients to become fans of this page because I believe there is an even greater likelihood of compromised client privacy and I do not want others who may look through my fans to assume you are my client.

If you are my client and I see that you have become a fan of my Facebook page, you can expect me to delete you as a fan and bring it up in our session when I see you next.

Please note that you will always be able to view all my Page content without becoming a fan or you can subscribe to the page via RSS without creating a visible, public link to my Page.

Following

I currently keep a professional Twitter stream and a blog on my practice website. If you use an easily recognizable (to me) name and I notice that you’ve followed me on Twitter, you can expect me to bring it up in therapy so that we can briefly discuss it.

My primary concern will be how it relates to your own privacy. There are more private ways to follow me on Twitter (such as subscribing using an RSS feed) which would eliminate your having a public link to my content. But you are welcome to use your own discretion in choosing whether to follow me. There is nothing I post here that I would not want you to see.

Please be aware that I will not follow you back.

I do not follow current or former clients on blogs or Twitter. If there are things you wish to share with me from your online life, I strongly encourage you to bring them into our sessions where we can process them together, during the therapy hour.

Interacting

I do have a professional presence on Twitter, Facebook, and LinkedIn. I also keep a blog. You are always welcome to read my content on these sites if it is of interest to you. But please do not use these sites to send me messages or to interact with me outside of treatment. If you need to contact me between sessions, the best way is by phone. Email is second best, but only for quick, administrative issues such as changing appointment times. Please see the email section below for more information regarding email interactions.

Use of Search Engines

It is NOT a regular part of my practice to search for clients on Google or other search engines. Exceptions to this may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, email) there may be a circumstance in which using a search engine to find another party close to you or seeing if you have or have posted to a blog, Facebook page, or Twitter may become necessary as part of checking on your welfare. These are extremely rare situations and If I ever resort to such means, I will definitely discuss this with you when we next meet.

Google Reader

I do not follow current or former clients on Google Reader. I also do not use this account to share articles with current or former clients. I share many links of interest via my Twitter account which you are welcome to read and I encourage you to bring your own items of interest into our sessions if there are things you want to share with me that you feel are relevant to your treatment.

Email

I prefer to use email only to arrange or modify appointments. Please do not use email to send content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, please be aware that all emails are retained in the logs of your and my internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. You should also know that any email I receive from you, and any responses that I send to you, will be printed out by me and kept in your treatment record.

Termination

As set forth above, after the first couple of meetings I will assess if I can be of benefit to you. I do not accept clients who in my opinion I cannot help. In such a case, I will give you a number of referrals that you can contact. If at any point during psychotherapy I assess that our work together is not effective in helping you reach the goals we have identified, I am obliged to discuss this with you and, if appropriate, to terminate treatment. In such cases I provide at least three referrals. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and with your written consent, I will provide them with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer. You have the right to terminate therapy at any time. I do however ask that if you decide to terminate that we have at least one exit session to review our work together.

MY BACKGROUND

I am a Licensed Mental Health Counselor in Massachusetts and a Licensed Marriage Family Therapist in California. I have practiced in the field of Mental Health since 1972 in various settings including Psychiatric Hospitals, Community Agencies, Group and Private Practice. I teach and supervise pre-licensed Mental Health Counselors and Marriage Family Therapists. I am certified in Hypnosis, EMDR (Eye Movement Desensitization Reprocessing), and Sensori-Motor Trauma Treatment. I am a Clinical member of the American Mental Health Counselors Association and the California Association of Marriage and Family Therapists and an Affiliate Member of the American Psychological Association. Membership in these associations requires that I follow their ethical guidelines. If you would like the contact information of any of my licensing boards or professional associations please ask so I can give you their current information.

By signing this form I the undersigned client acknowledge that I have both read and understood all the terms and information contained herein. I have been given ample opportunity to ask questions and seek clarification of anything unclear to me.